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During general anesthesia the entire body including the brain is put to sleep; you will be completely unconscious during the operation. Under this type of anesthetic the patient feels nothing and generally remembers nothing about the procedure. The medication is given through intravenous injection, by mask or by both.

Once the patient is settled in the OR, the anesthesia team sets up heart, blood pressure and breathing monitors, after the patient is asleep a number of procedures are carried out to assure safety. Since general anesthesia can impair normal breathing, some assistance is necessary with respiration. Most often a breathing tube is placed in the wind pipe after the patient is asleep. This is removed as the patient is awakening and most patients will not remember having the tube in place. A mild sore throat is common and may last a day or two. Dentures and retainers should be removed before surgery and if you have any loose teeth, please let the anesthesiologist know, as special intubation technique may be required.

After the procedure, the anesthesia provider will monitor patients in the post-operative care unit until they wake up.

Thoracic Anesthesia

Patients that present for minimally invasive, and more complicated lung procedures, often have a host of lung, heart and systemic medical problems. The nature of the procedure and the unique medical profile of such patients pose significant challenges for both surgeon and anesthesiologist. Our anesthesiologists are trained in a variety of techniques designed to optimize perioperative outcome. These include invasive monitoring, one lung ventilation and thoracic epidural anesthesia.

Bariatric Anesthesia

At our institution, surgeons perform surgery indicated for patients that are morbidly obese, including both malabsorptive and restrictive procedures. Frequently patients present with a constellation of findings such as diabetes, obstructive sleep apnea, high blood pressure and pulmonary dysfunction. Our critical care anesthesiologists routinely implement a host of specialized measures aimed at increasing the safety of surgical intervention.

Regional Anesthesia and Pain Management

Many surgical patients today are concerned about how their pain will be managed after the surgery is completed. Physician Anesthesia Associates, P.A. is pleased to offer patients post-operative pain management for many surgical procedures. This may be obtained through a combination of intravenous or oral pain medication (prescribed by your surgeon) and regional anesthesia (more commonly known as a nerve block). The latter involves the injection of local anesthetic in close proximity to the nerves that conduct impulses to the spinal cord and brain. Nerve blocks can be obtained by injecting local anesthetic close to the nerves near the surgical site (distal block) or through a centrally acting nerve block (spinal and/or epidural).

Regional anesthesia is usually administered in combination with general anesthesia for most procedures; however, it can serve as the primary anesthetic, usually combined with intravenous sedation. Nerve blocks may also be combined to provide better therapeutic effect. The type of regional anesthesia offered, if any, depends on the type of surgery you are having, duration, and your medical condition. There can be variation in the pain relief provided, as pain is a subjective process. If you do not receive regional anesthesia, your post-operative pain will be managed by your surgeon after discharge from the post-operative care unit (PACU).

Your anesthesia care provider can discuss the benefits and risks of regional anesthesia during the pre-operative interview and will determine if a nerve block can be offered for your type of surgery and medical condition. Listed below are examples of blocks that are offered; however, this list is not all-inclusive.

Types of Distal Blocks:

Brachial Plexus (Interscalene, Supraclavicular, Infraclavicular, Axillary): This block is provided for surgeries of the upper extremity and can provide approximately 12 hours post-op pain relief.

Wrist Block: This block is provided for surgery of the lower hand or fingers. It can provide approximately 10 hours post-op pain relief.

Bier Block: This is an intravenous regional anesthetic combined with sedation for surgeries of short duration on the lower arm. Infiltration of local anesthetic at the wound site provides post-op pain relief.

Paravertebral/Intercostal: This block is provided for certain chest (e.g. radical masectomy) and lower abdominal surgeries.

Ilioinguinal/Iliohypogastric: This block, in combination with infiltration of local anesthetic at the wound site, can provide pain relief for open inguinal hernia repair up to 8 hours.

Lumbar Plexus: This block is provided for surgeries of the hip and upper thigh. Pain relief generally lasts 12 hours.

Sciatic Block/Popliteal: This block is provided for surgery of the hip, upper, and lower extremity. Pain relief generally lasts 12 to 15 hours.

Femoral/Obturator: The block is provided for surgery of the upper leg and/or knee. Pain relief generally lasts 12 hours.

Ankle Block: This block is commonly provided for surgery involving the foot and not the ankle itself. It is commonly used in combination with intravenous sedation for podiatric procedures.

Types of Central Neuraxal Blocks:

Spinal: This type of block involves the injection of local anesthetic through a tiny needle into the spinal space that contains fluid below the spinal cord. The anesthesia lasts for a given amount of time depending on the type of medication used, and then wears off. This block is usually combined with intravenous sedation.

Epidural: This type of block involves the placement of a tiny catheter into the fatty space that exists outside of the spinal space and allows the continuous infusion of local anesthetic to provide pain relief. It is usually placed pre-operatively under sedation. It can be used alone with intravenous sedation or combined with general anesthesia for the duration of the surgery. The catheter may then be utilized post-operatively for several days to provide pain relief. Examples of surgery using an epidural include: Thoracic cases, exploratory laparotomies, bilateral knee replacements.

During sedative anesthesia a patient is usually relaxed and perhaps sleeping lightly but can wake up in response to question, Patients are not expected to lose total consciousness but are comfortable and often have no memory of the OR experience. Sedation is generally used to supplement local or regional anesthesia in order to increase a patient's comfort and peace of mind.

Local anesthesia involves numbing a very limited, specific area of the body. It is generally used in minor surgery or in conjunction with regional or sedative anesthesia. It can be injected or applied as a ointment, cream, drops or spray. The affected area stops the nerves from sending signals to the brain, so that area will feel numb. This type of anesthesia involves few risks.

Physicians Anesthesia Associates is comprised of board certified anesthesiologists and certified nurse anesthetists; all of whom are trained in administering anesthetics to children. In an effort to ensure the highest quality of care for the smallest and sickest children, the practice has five fellowship trained pediatric anesthesiologists. These physicians have experience in the anesthetic management of rare and complex pediatric disorders.

Frequently asked questions:

Does my child really have to go without food or drink before surgery?

Yes, but not for as long as in years past. Our current guidelines do not allow for solids after midnight; however, clear liquids like pulp less fruit juices, soda, broth, and Jell-O are permitted up to 3 hours prior to surgery. Breast milk is permitted up to 3 hours prior to surgery; however, formula can only be given up to 6 hours prior to surgery. Remember, clear liquids mean clear liquids. If you can't see through it or there is something solid in it such as a noodle don’t eat it, lest you be postponed. When in doubt, call us.

Can I be present while my child is going to sleep?

As a rule, yes; however, this is ultimately the decision of the attending anesthesiologist who will weigh the pros and cons in your child's specific case. Children who benefit the most from having either Mom or Dad present are 18-24 months and older. In children under a year and a half of age; there are no studies to support that the child benefits from parental presence; however, this is assessed on a case by case basis. Finally, for safety reasons, we do not allow family to be present during the induction of anesthesia in children under the age of one. Only one parent is allowed back into the operating room during induction.

Will my child be given a needle or a mask?

The most common approach to anesthetizing young children is by breathing anesthetic gas through a bubble gum scented mask; this stands to reason as nearly all young children dread ‘the needle’. Older yet pre-teen children are given the option of an IV. Thus a child’s age and maturity plays a major role in determining how they go off to sleep. There are, nonetheless, several overriding exceptions. Among these are a family history of malignant hyperthermia, a potentially deadly inherited susceptibility to certain anesthetic medicines, and emergencies such as appendicitis. Under these circumstances, the insertion and induction of sleep through an IV is considered the safest approach. The other exception is when the child volunteers a preference for an IV or refuses all available options.

Can I be present when my child wakes up?

Yes, the recovery room nurses are attuned to this and will bring you in to the recovery room when you child has emerged sufficiently from the anesthetic. When your child is fully awake and able to drink fluids, the surgeon will determine when they can be discharged. Infants and children recover quickly from the stress of anesthesia and surgery. They experience less post-operative pain and complications than adults. However, they will be monitored closely until discharge.

If you have any questions or wish to discuss an unusual aspect of your child's medical history, a pre-operative consultation with a pediatric sub-specialist is available at no charge. Please call 443-849-2202 for an appointment.

Physicians Anesthesia Associates, PA. provides 24 hour coverage, 365 days a year, to the labor and delivery (L&D) suite at GBMC. An anesthesiologist is assigned to L&D at all times. This means that patients will rarely wait more than a few minutes for an anesthesia consult once it is requested.

A number of options are available to reduce the pain associated with labor and delivery. The choice and timing of pain relief methods will vary from patient to patient and even from pregnancy to pregnancy in the same patient. It is often said that no two pregnancies are alike. You and your doctor will decide on the best method of pain control during your labor.

Intravenous and Intramuscular Medication

Early in labor your obstetrician may offer you intravenous or intramuscular injection of medication to ease the pain of labor. Narcotics such as butorphanol (Stadol), are often used. Narcotics will help with mild contractions in early labor but typically are insufficient to relieve the stronger contractions associated with active labor. Narcotics administered to the mother will reach the baby through the mother's blood stream and may make the newborn sleepy, so they are avoided as delivery approaches. An anesthesiologist is usually not involved in this type of pain management.

Epidural and Spinal Analgesia (regional anesthesia)

As your labor progresses, your obstetrician may request an anesthesiology consult to offer you more effective labor analgesia (pain relief). Your anesthesiologist will ask a few questions about your medical history to be sure that regional analgesia is appropriate for you. Of special concern are any bleeding disorders, active infections, or prior back surgery.

Timing

The best timing for this type of intervention depends on a number of factors including your medical and obstetrical history. Strictly speaking, it is never too late to have a regional anesthetic; but since it requires 5-10 minutes of patient cooperation (i.e., holding reasonably still) and takes 10 -15 minutes for the medicine to work, it becomes impractical when the patient starts pushing.

An early epidural is recommended in patients with a higher risk of needing a Cesarean section. Once the epidural is in place, it can be quickly dosed to provide anesthesia for a C-section if that becomes necessary, avoiding any undue delay. Patients at higher risk of needing a C-section include those with a history of prior C-section, patients with pre-eclampsia (toxemia), and patients with early signs of fetal distress.

The issue of whether epidurals slow labor is a controversial one. Research has suggested that first time mothers who have an epidural placed before reaching 4-5 cm of cervical dilation and engagement of the fetal head in the birth canal MAY be at risk for a prolongation of their labor. However, the widespread use of Pitocin augmentation for labor has greatly minimized this concern.

Fetal Effects

Any medications that enter the maternal bloodstream are able to reach the fetus. Epidural and spinal medications are not injected into the blood but are slowly absorbed from the epidural and spinal space into the bloodstream and metabolized by the mother. Actual blood levels are, therefore, very low and usually have negligible effects on the fetus.

Regional anesthesia may affect the fetus by changes that occur in the mother's body. For example: As the medicine takes effect and the mother becomes comfortable, the maternal blood pressure may decline. The baby may respond to this abrupt drop in blood pressure with a transient fall in heart rate. When this occurs, it is usually treated with IV fluids and medicine to raise the blood pressure. It will resolve in several minutes as the mother's body becomes accustomed to the epidural effects.

There are also beneficial affects to the fetus. The reduction in maternal pain reduces hyperventilation and the release of stress hormones, which improve blood flow to the fetus. In patients with pre-eclampsia and high blood pressure, the epidural may relax (dilate) the mother's blood vessels, improving blood supply to the baby. Late in labor, the relaxation of the pelvic muscles and the reduced urge to push allows the baby's head to descend and the perineum to stretch slowly, thereby reducing the risk of a large episiotomy or tear.

Epidural technique

The patient is placed in either the sitting position or on her side and asked to curl up as much as possible. This curled up posture opens the spaces between the bones in the spine and allows access to the epidural space. The lower back is washed with a sterile solution of iodine or alcohol. A small needle is used to inject local anesthetic (numbing medicine) in the skin. This injection produces a 10-20 second stinging sensation. Once this area (about the size of dime) is numb, the patient will feel mostly pressure during the remainder of the procedure. A thin flexible plastic tube is placed through the area that is numb into the epidural space and taped along the back.

Test dose

Once the epidural is in place it must be tested prior to its use. The test dose is designed to alert the anesthesiologist to an inadvertent placement of an epidural catheter into a vein or the spinal space.

Veins are present in the epidural space, as they are throughout the body, and the tip of the epidural catheter can sometimes thread into one of these veins and must be replaced. The catheter may also be inadvertently placed into the spinal space, in which case it must be dosed with a different amount of medicine. The test dose contains a small amount of local anesthetic and epinephrine (adrenaline). When the catheter is in the epidural space, this test dose of medicine is too small to have any effect. If the catheter is in a vein, the patient will experience a transient increase in heart rate and/or mild ringing in the ears. When an inadvertent spinal is in place, this small amount of medicine will cause complete pain relief and numbness in the legs within minutes.

Epidural dosing

Once the test dose is completed and proper placement confirmed, the epidural is dosed with a combination of local anesthetic and narcotic. This medicine will take 10 to 20 minutes to reach its peak effect, during which time each contraction will feel better then the previous one. Once a satisfactory comfort level is reached, a slow infusion will be started to maintain that level until delivery. The patient may feel some pressure with each contraction. The goal is to provide relief of pain without interfering with the mother's ability to push at delivery. An additional "delivery dose" may be needed as delivery approaches.

There are times when your obstetrician may want to reduce your epidural infusion to increase your ability to push. When this happens, you may begin to feel more of the contractions. As always, our priority is your safety and the safety of your baby.

Risks of regional anesthesia

1. The most common problem with labor epidurals is incomplete pain relief. Occasionally the epidural will provide only one-sided pain relief or no pain relief at all. When this occurs (about 2%), the epidural will need to be replaced.
2. Bleeding in the epidural space is a very rare but serious complication. This is seen almost exclusively in patients with bleeding disorders. If you have a history of a bleeding disorder, please tell your anesthesiologist before epidural placement.
3. Infection at the epidural site is a rare complication.
4. Allergic reactions to the epidural medications are also possible but rare.
5. Spinal headache after epidural placement can occur if the spinal space is inadvertently entered during epidural placement. Go to spinal headaches and their treatment for more information.
6. Back pain is common after labor and delivery and its cause is multifactorial. There may be some soreness at the epidural placement site for a day or two similar to soreness you may have at the IV site. Several large studies have shown that after 1 week, there is no difference in back pain between patients who had an epidural and patients who delivered naturally.

Spinal technique

The technique for placement of a spinal anesthetic is essentially the same as for an epidural. However, instead of a catheter being placed into the epidural space, a tiny needle is used to inject local anesthetic and/or narcotic medication into the spinal fluid. The advantages of a spinal injection are that it is generally easier to perform, highly reliable and provides almost immediate pain relief. The disadvantage is that, since it is a one time injection (i.e. no catheter inserted as with an epidural), it will only last 60-90 minutes. This makes it useful mostly for patients who present late in labor and will likely deliver rapidly. Occasionally, a combined spinal and epidural can be placed to achieve the benefits of both techniques.

Nerve Injury

The most common nerve injury (still rare) that occurs during labor and delivery is called meralgia paresthetica. This is only indirectly related to anesthesia. During the pushing phase of labor and delivery, the mother will be asked to pull the knees back toward the chest to help allow the baby's head to pass into the perineum. When there is prolonged pushing the legs may be in this position for some time. This may cause a pinching of the femoral nerve that passes through the inguinal (thigh) area. When this nerve is injured, it may cause numbness or pain in the thigh and even weakness in the leg. Usually recovery occurs over time but may take weeks to months. An epidural may increase the likelihood of this injury because the mother may not appreciate the awkwardness of the knee to chest position and is less likely to relax her legs between contractions. So remember to relax the legs in between contractions to avoid prolonged pressure on this nerve during labor.

Anesthesia for Cesarean section

Whenever possible, a regional anesthetic technique (spinal or epidural) is preferred in patients undergoing Cesarean section. Anatomic and hormonal changes that occur during pregnancy cause the pregnant patient to be at increased risk for complications with general anesthesia.

Elective C-section

Spinal anesthesia is often recommended for elective C-section because of its quick onset and reliability. Epidural anesthesia may also be used but takes a bit longer to achieve the necessary level of anesthesia to begin surgery.

Urgent C-section

An epidural, when already in place for labor, can be dosed with a more concentrated anesthetic solution to provide anesthesia for C-section. When an epidural is not in place, a spinal anesthetic is most often used to provide prompt onset of surgical anesthesia. In cases where regional anesthesia is contraindicated (i.e. unsafe), such as in a patient with a bleeding disorder, general anesthesia is required.

Emergency C-section

When the mother or baby is in severe life threatening distress, general anesthesia is the fastest way to provide surgical operating conditions. Under these circumstances, no time is available to initiate regional anesthesia. Fortunately, this is an uncommon situation.

Risks

1. The most common complaint (~50%) during C-section is nausea and vomiting. This is due to rapid changes in blood pressure that accompany the onset of spinal anesthesia and to traction on intra-abdominal structures during surgery. It usually comes in waves and passes in a few minutes. Medications to help can be given should this occur.
2. Occasionally the numbness from the anesthetic will spread to the chest wall. Normally you are subconsciously aware of the chest expanding and contracting as you breathe. When you lose that sensation it gives you the illusion of being short of breath. The anesthesiologist carefully monitors the level of oxygen in your blood and reassurance is all that is required. This sensation will subside shortly. Heaviness in the chest is also frequently reported during C-section.
3. Blood loss during C-section can sometimes be significant enough to require a transfusion. Blood products will be given only when it is absolutely necessary. The blood bank will prepare blood that is specifically matched to the patient's blood type and screened for infectious diseases should a transfusion be required.
4. There is a risk of an allergic reaction to any medications given. Allergic reactions range in severity and are usually treatable.
5. General anesthesia is available at any time and is reserved as a back-up plan for emergencies.

Sedation during C-section

Sedative medications are usually withheld until after the baby is delivered so as not to sedate the baby and impair evaluation of the newborn. After the baby is delivered, the mother may request mild sedation at any time during the surgery (unless medically unadvisable). Many patients are quite comfortable and will not need or want any additional medicine but it is available to "take the edge off" while lying still for the repair and closure of the abdomen.

More Information

Physicians Anesthesia Associates, PA offers a free consultation service to GBMC patients to discuss any issues or concerns you may have regarding your anesthetic care. To schedule a free consultation with a board certified anesthesiologist at GBMC, call 443-849-2202.